Wednesday, October 31, 2012

I have been on vacation with family for the last 2 weeks. We travel quite a lot and we do enjoy it. Most of the time the journeys are done by train and for quite a long time, they would continue to be by train as the there is hardly any hope of airtravel costs coming down.

We were planning to return the next Friday. However, certain compulsions back at NJH needed us to reach back couple of days earlier. Which meant that we took a decision to take Tatkal tickets.

Well, I have heard of enough stories on how harrowing it could be. Booking on the IRCTC website was totally out of question. I expected it to be a tough 24 hours. And I was well prepared. However, the experience was hilarious.

The decision was taken a couple of days back. The reservations for the tatkal ticket opened at 10 AM on the day immediately preceding the day of travel.

I thought of doing some ground work on how the whole system worked 2 days before I was supposed to take the ticket. To my horror, I found out that the queue for taking the tatkal ticket started more than a day before the allotted time for starting the reservations. Considering the long queue I witnessed at Trivandrum Central Railway Station, the situation was much better at Chengannur Railway Station.

People came and lay on the floor outside the veranda of the reservation counter overnight. There was a sheet of paper on which people wrote their names. You''ll understand more when I show you few snaps.

I had to travel anyway.

I had to take my ticket on the 30th October at 10:00 am. With only 6 tickets available for grabs, I had only a small margin of error. I was there in the Railway Station at 2:00 pm on the 29th October. Thankfully, there was nobody else. I had taken a sheet of paper on which I wrote my name. I filled out one application form and laid it on the veranda with couple of stones on top.

My reservation form on the floor. You can see the paper sheet for listing the names of the passengers.

I waited till around 5:00 pm, when another passenger turned up. The habit of reading helped me to pass my time fast. Soon, there were 2 more. I left my position and went home after telling the people after me that I would come back soon. I was back by 8 pm. There were a total of 6 people in the line. I was relieved that nobody tampered my position at the head of the line.

Soon, we had developed a sort of camaraderie. The rest of the group was shocked to know that I had come at 2 in the afternoon. There were couple of them who did not come with photocopies of the ID card. I helped them get the copies. They had become very indebted to me and requested me to go home and come back in the morning. I was not very inclined, but sleep was slowly beckoning me back home.

I returned home by around 10 pm. The plan was to go back again at midnight. . . . which ultimately never materialised. However, I woke up at 4 am and went there. There were some 10 people now in the queue. My new found friends told that everything is fine. I returned home.

I returned again at 6:30 am. There were about 20 people in the line now. At 7:40 am, the booking clerks arrived and gave us token numbers. Later, I returned for the last time at 10:00 am and got confirmed tickets for my journey.

In spite of the fact that the Indian Railways has the largest rail network, the facilities available for reserving tickets are quite archaic. The internet portal is a nightmare. I hope with the recent change in guard, things will improve.

I’m certain that we in India have a lot to learn from the
European countries on how tuberculosis was controlled. I quote the Lancet paper
. . .

Riding on the antibiotic wave in the 1960s, tuberculosis
increasingly failed to trouble public health authorities in developed
countries. Chest physicians and surgeons reoriented their interests;
tuberculosis journals and antituberculosis charities widened their remit. At
the same time, many nascent eff orts in the developing world were stalling. Not
enough attention was paid as the world entered economic turmoil in the 1970s
and expensive vertical disease programmes were replaced by a new emphasis on
primary health care. Tuberculosis rates remained high, fuelled by social
determinants, poor living and working conditions, poor medical infrastructure,
and high comorbidity.

I’m a bit sad to infer that the author unknowingly seems to
berate the new emphasis on primary health care. However, please do note that in
India, we have the vertical disease programme which has been quite expensive
and has unfortunately not produced the sort of result we’ve seen in countries
like China. We have a robust primary health care system on paper. However, most
of us very well know that in many a state the primary health care system is
just for namesake.

I would be very much interested to know the incidence rates
calculated for the different states of the country. I understand that studies
are on to find out the latest incidence rates.

From the incidence rates which were accepted about ten years
back, most of the better off states in social indices had a lower incidence
compared to the EAG states. As mentioned in the Lancet article, social
determinants, poor living and working conditions, poor medical infrastructure
etc has fuelled tuberculosis in countries such as ours. I’m surprised that the
author left out malnutrition and smoking.

Any doctor seeing tuberculosis cases will vouch that almost
all of his patients are poor and quite a huge proportion of them are addicted
to tobacco and alcohol. Most of them live in cramped one room huts in the
villages (along with his cattle and sheep) or shanties in the cities with
hardly any food to eat. And once a person has tuberculosis his whole world
caves in. He gets into a vicious cycle where the disease makes him weak to earn
a living; the lack of work makes him poor and the tubercle bacteria feeds on his
poverty stricken body mass starting at the lungs.

I’m not sure on how we reduce poverty in a country as large
as ours. But, one thing we can do is to decrease the effects of poverty
especially the aspect of nutrition. I believe that targeted food subsidy has
failed. The corruption of this country is so much that subsidised food never
reaches the target population.

There have been on and off stories of self sufficiency and
empowered food security in certain pockets. But on a larger scale, we are
nowhere when it comes to providing good nutrition to our people. It is only the
well affording who can buy nutritious food. To make matters worse, we have
enough beliefs about food that the sick are forced to follow. It is not
uncommon to find our patients avoiding eggs, milk etc.

With enough and more reports about high numbers of malnourished children in our communities, the same should hold true even for adults.
Recently, my better-half did a small study in the hospital of the
characteristics of our outpatient crowd. She found that 37% of our outpatient
crowd had a BMI of less than 18.5. And our patients are usually the lower middle
class and above and not the really poor. If this is the case, I wonder what
would be the condition of the really poor.

Solving many of our country’s scourges of ill health would
be to offer a robust system of public distribution of nutritious food for each
of its citizens irrespective of how poor or rich they are. Various types of
food distribution systems which are immune to market fluctuations and
inflations have to be somehow worked out.

So, my solution number one to decrease the incidence of
tuberculosis in the country . . .a
ROBUST PUBLIC DISTRIBUTION SYSTEM OF FOOD. I welcome suggestions . . .

We spent 2 days relaxing at a quiet fishing village some 70 kms away from Trivandrum city. The place's name is Muttom, Kanyakumari district, Tamil Nadu. Few of the snaps taken on the day we visited the local village fishing harbour early morning when the fishermen were returning after a whole night of fishing.

2. 26% of the burden is in India, which means every minute we have 4 new cases of tuberculosis in the country.

3. Every 2 minutes, 5 people die of tuberculosis somewhere in the world of which one person is from India. However, it is much better than the earlier statistics which taught us that 2 tuberculosis deaths occured in India alone every 3 minutes. Recalculating, it's now 2 tuberculosis deaths every 4 minutes, or to make it more easier, one death every 2 minutes.

4. There is approximately 300,000 MDRTB patients in the world of whom only 20% patients (60,000) have been identified.

I tried to reput some of the graphs comparing few of the countries with India.

As you can well see, our Achilles heel is the Case Detection Rate. For many reasons, we have not been able to make any sort of improvement over the last 15 odd years.

We at NJH also find it quite difficult to improve the Case Detection Rate and as far as I understand we are one of most under performing Tuberculosis Unit in this area. I tried to put down on what I think are the major reasons.

A. Leave alone the public health care providers, the primary care provider for a patient with cough is not even a proper doctor. When we see the patient with more than 2 weeks cough at NJH, in 95% of the cases they would have already taken some form of anti-tuberculosis treatment. And most of the time it would be the some INH-RIF combination given in sub-therapeutic dosages. Therefore, even our sputum positivity rates suffer as the drugs would have cleaned up the sputum. Most of the patients who reach us are already in a advanced state and it is with great difficulty that we get to cure them.

B. Many a time, anti-tuberculosis drugs from outside RNTCP is started without the patient being informed. Now, this is terrible as patients take the medicines for 1-2 months and stop as they feel much better. It is only when they bring old prescriptions that we realise that the patient has been given Anti-Tuberculosis treatment.

C. The quinolone group of antibiotics (ciprofloxacin, levofloxacin etc) are commonly used to treat Respiratory Tract Infections in Indian settings. I propose that this is very detrimental in tuberculosis treatment as almost this group of antibiotics have anti-tuberculosis properties and they are in fact used in MDRTB management. To put it short, the rampant use of antibiotics could end up fueling MDRTB as well as delaying the diagnosis of tuberculosis.

D. Of late, I've seen quite a number of patients who have been told elsewhere (many of them senior consultants of Respiratory Medicine and Internal Medicine) that the Government Medicines are not good. We have quite a few patients who have insisted that they buy branded medicines for tuberculosis from the drug store than take free RNTCP drugs. We make such patients write a consent before we allow them to do it.

Well, I can go on and on . . . We need to think of solutions faster. Otherwise, within a span of a decade, we could be facing the onslaught of Multidrug Resistant Tuberculosis. The emergence of XDR-TB makes things worse.

Complicating matters is the complex nature of the disease. Any clinician can easily tell you that it is not too easy a diagnosis many a time. Socio-economic factors also play a major part. The fact that there is strong association between tuberculosis and malnutrition and use of tobacco almost spells the death knell for South Asians.

Recently, when I was discussing the issue of Tuberculosis Control in India, one of my friends commented on whether the program was blemishless. Considering into fact that our country and it's leaders has become a byword for corruption, it is my sincere hope that there is not even an iota of corruption in this programme.

I hope that I would be able to discuss possible solutions and loopholes which would need to be plugged under the present RNTCP of the Indian Government in the next few articles.

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Welcome

I'm Jeevan. Along with Angel, my wife and four energetic kids - 2 daughters, Charis (6 years) and Hesed (4 years) and 2 sons, Shalom (9 yrs) and Arpit (2 years), we live in a remote town in North India.

We serve at a small dispensary attached to a Catholic mission which in addition to the clinic also has a parish and an ICSE school. We serve the most poor, backward and marginalised groups in the surrounding community. I use this blog to share about the people whom we serve and care for and our lives.